Article 1
Association of Prehospital Needle Decompression with Mortality Among Injured Patients Requiring Emergency Chest Decompression. Muchnok D, Vargo A, Paul Deeb A, Guyette FX, Brown JB. JAMA Surg. 2022 Oct 1;157(10):934-940.
Prehospital needle decompression (PHND) is a potentially life-saving intervention performed by emergency medical services (EMS) to decompress suspected tension pneumothorax in sick trauma patients. However, data to support its effectiveness is limited and concerns exist that prehospital procedures delay ‘scoop-and-run’ to definitive care. In this study, the authors sought to evaluate whether PHND improved survival in patients requiring emergency chest decompression. The study population were adult patients treated at 44 Pennsylvania trauma centers over a 20-year period. The treatment group received PHND identified by ICD procedure codes. The control group received a chest tube within 15 minutes of hospital arrival, but not PHND. The primary outcome was 24-hour mortality. The authors used sophisticated methodologies to control for confounding, including multilevel logistic regression, propensity score matching, and instrumental variable analysis. They also performed important subgroup analyses, such as patients with severe chest injury and documented pneumothorax.
Among 8,500 eligible patients, 11% received PHND. Treatment with PHND was more often associated with blunt trauma, helicopter EMS transport, prehospital intubation, and longer prehospital time. After risk-adjustment, PHND was associated with 25% lower odds of 24-hour mortality compared to chest tube without PHND (OR 0.75; 95% 0.61-0.94). This finding was consistent across statistical approaches and subgroup analyses. There are important limitations to these findings. Use of a hospital-based registry with high degree of missing prehospital data clouds the causal chain of events from time of injury to hospital arrival and indications for PHND were unknown. Unmeasured confounding is likely to persist due to underlying differences between PHND and early chest tube groups. However, 1-in-3 patients that received PHND had improvement of prehospital physiologic abnormalities, supporting the biologic rationale for improved survival. In addition, patient factors explained only 12% of variation in use of PHND, indicating that differences in utilization may be driven more by differences in EMS training and protocols. Taken together, the study findings support that PHND is likely a life-saving maneuver that is relatively underutilized. Efforts to standardize patient selection and reduce variation in practice are needed.
Article 2
The small (14 Fr) percutaneous catheter (P-CAT) versus large (28–32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. Kulvatunyou N, Bauman ZM, Edine S, de Moya M, Krause C, Mukherjee K, Gries L, Tang AL, Joseph B, Rhee P. J Trauma Acute Care Surg. 2021 Nov 1;91(5):809-813.
Traumatic hemothorax (HTX) has traditionally been treated with large caliber chest tubes (28-36Fr) with the belief that this is necessary to achieve effective drainage of blood. However, large chest tubes placed by open cutdown technique are painful, and there is growing evidence that smaller caliber percutaneous catheters (PCs) may be equally effective. In this multicenter randomized non-inferiority trial, the authors build upon their own single center evaluation of PCs for evacuation of traumatic HTX. Adult trauma patients treated at 4 participating trauma centers were eligible. Patients that required drainage of traumatic HTX were included. While guidance was provided to use a HTX volume of 300cc as threshold for drainage, the decision was at discretion of the treating physician. After consent was obtained, treatment allocation was performed by block randomization within each center. The treatment group received a 14F PC placed by modified Seldinger technique. The control group received a conventional 28-36F chest tube. The primary outcome was drainage failure, defined as retained HTX requiring subsequent intervention. Secondary outcomes included an ‘insertion perception score’ (IPE) – a subjective scale to capture the patient’s experience with the procedure ranging from 1 (can tolerate, can do it again) to 5 (worst experience). Sample size calculations estimated need for 95 patients per arm, using a non-inferiority margin of 15% based on prior studies.
Over a 5-year period, 120 patients were enrolled. The trial was terminated early due to interruption by the COVID-19 epidemic. PC and chest tube patients were similar with regards to mechanism, ISS, and pattern of chest wall injury. The rate of failure was similar between PC and chest tube groups (11 vs. 13%, p = 0.74). PC insertion was significantly more tolerable to patients compared to chest tube placement (median IPE, 1 vs. 3, p < 0.001). Other outcomes were comparable. There are important limitations to this study. Foremost, the study did not achieve its enrolment target, leaving potential for an undetected difference in effectiveness between interventions (Type II error). Consent was required for enrolment so patients that received emergency chest tubes were excluded. Therefore, the study should not be generalized to the earliest acute phase of care. Despite these limitations, the study provides compelling data to support that PCs are equally as effective as larger caliber chest tubes at draining HTX in stabilized trauma patients. Considering benefit to patient experience, PCs should probably be the intervention of choice in this setting.
Article 3
Reading the signs in penetrating cervical vascular injuries: Analysis of hard/soft signs and initial management from a nationwide vascular trauma database. Marrotte A, Calvo RY, Badiee J, Rooney AS, Krzyzaniak A, Sise M, Bansal V, DuBose J, Martin MJ. J Trauma Acute Care Surg. 2022 Nov 1;93(5):632-638.
Operative intervention for penetrating cervical trauma is encouraged by many algorithms that center on the presence of hard signs, including active hemorrhage, pulsatile or expanding hematoma, airway compromise, and hematemesis and subcutaneous emphysema signaling aerodigestive injury. Recent literature has begun to reexamine this recommendation of mandatory exploration for vascular injury. The authors of this study analyzed the large American Association for the Surgery of Trauma (AAST) national Prospective Observational Vascular Injury Treatment (PROOVIT) database to specifically examine the association between hard signs and need for operative intervention and outcomes in patients with penetrating cervical vascular injuries (PCVIs). Patients were categorized by presence of hard signs or soft signs, and subsequent imaging and surgical exploration rates were compared. The primary outcomes were operative management of the vascular injury or observation. Of 110 PCVI patients with hard signs (hemorrhage, expanding hematoma, or ischemia), 61 (56%) had immediate operative exploration and 44% underwent CT imaging. Following CT, 20 (18%) required open repair, 7% had endovascular intervention, and 19% required no operative intervention. In these patients with hard signs, there was no difference in mortality between those undergoing operative intervention versus observation alone (23% vs. 17%, p = 0.6).
This study is the first analysis of the PROOVIT database with a focus on patients with penetrating cervical vascular injury. It examines in great detail the natural history of patients that were initially managed non-operatively with observation alone, and adds to the expanding body of evidence examining hard signs as a waning indication for mandatory operative exploration. The authors conclude that hard signs should not be considered an absolute indication for immediate surgical exploration and a significant proportion who are hemodynamically stable and with a secure airway might benefit from initial CT angiography imaging, undergo far less invasive interventions, or possibly even avoid surgery. However, these findings must be examined in light of the fact that inclusion in the PROOVIT database requires presence of a named vascular injury. For this reason, indeed, the authors state that “this analysis cannot be used to determine sensitivity, specificity, or predictive value of hard signs.” Further, the decision to operate or not despite presence of hard signs is also based on clinical judgement and these nuances are not accounted for in a database.
Article 4
Prospective evaluation of the selective nonoperative management of abdominal stab wounds: When is it safe to discharge? Owattanapanich N, Cremonini C, Schellenberg MA, Schellenberg MA, Matsushima K, Lewis MR, Lam L, Martin MJ, Inaba K. J Trauma Acute Care Surg. 2022 Nov 1;93(5):639-643.
In the absence of indications for immediate operative intervention, patients suffering from abdominal stab wounds may be carefully-selected and managed by selective non-operative management (SNOM). This typically includes an initial CT scan following which, excepting any findings necessitating operative intervention, patients are observed. This optimal period of observation should be of sufficient duration so as to clinically reveal occult injuries. Prior retrospective studies have suggested an observation period of at least 12-24 hours before safe discharge of these patients. This is the first study that prospectively examines SNOM in patients with abdominal stab wounds to determine the optimal period of observation. Demographics, clinical and injury data, and outcomes in patients presenting at a single level I trauma center were examined. The primary study outcome was time to SNOM failure, defined as the need for surgical intervention after an initial period of observation. 179 patients underwent SNOM. Three patients (2%) failed SNOM and underwent laparotomy between 10 and 32 hours after arrival, with gastric or small bowel injury, or a nontherapeutic laparotomy. All patients who failed SNOM for a hollow viscus injury did so within the first 24 hours of presentation. The authors therefore recommended a period of 24 hours of close observation for SNOM.
Selective nonoperative management is a management strategy which balances the risk of missed injury and delay in diagnosis with the complications and costs associated with a nontherapeutic laparotomy. This study attempts to further the understanding of SNOM by evaluating the ideal period for observation and is a great effort towards that goal. However, some patients undergoing SNOM were observed for as little as 48 hours (SNOM overall 60 (48–96) hours), while overall 24 patients were observed for less than 24 hours. The authors rightfully indicate the possibility that some of these patients could have a hollow viscus injury that may manifest clinically after 24 hours, with the patient presenting to a different trauma center. Furthermore, while the authors rightfully included patients who had suffered from flank and back wounds, signs of clinical decline from a retroperitoneal colon injury have been known to present even later than 48 hours despite a negative initial CT especially after stab wounds. Extending the period of observation for patients suffering from such wounds would be ideal.
